A nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a violation?

Placing a client in restraints without having a healthcare provider’s order.

Administering the medication to a client behind a closed curtain.

Informing a client that the medication being administered is a vitamin.

Enlisting security personnel to assist with restraining the client.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Placing a client in restraints without having a healthcare provider’s order is a violation of patient rights and safety protocols. Restraints should only be used when absolutely necessary and with proper authorization to ensure the safety and well-being of the patient. Unauthorized use of restraints can lead to physical and psychological harm, and it is essential to follow established guidelines and obtain the necessary orders before applying restraints.

Choice B rationale

Administering the medication to a client behind a closed curtain is not a violation. This action ensures the client’s privacy and dignity during the administration of medication. Maintaining privacy is a standard practice in healthcare settings to respect the patient’s confidentiality and comfort.

Choice C rationale

Informing a client that the medication being administered is a vitamin is a violation of ethical and legal standards. It is essential to provide accurate information to the patient about the medication being administered. Misleading the patient can undermine trust and lead to potential harm if the patient has allergies or contraindications to the medication.

Choice D rationale

Enlisting security personnel to assist with restraining the client is not a violation if done appropriately. In situations where the client poses a danger to themselves or others, it may be necessary to involve security personnel to ensure safety. However, this should be done following proper protocols and with the necessary orders in place.

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Correct Answer is A

Explanation

Choice A rationale

Injecting in the abdominal area at least 2 inches (5.1 cm) from the umbilicus is the correct technique for subcutaneous heparin injections. This reduces the risk of injury to blood vessels and nerves and ensures consistent absorption of the medication.

Choice B rationale

Rotating injections between the abdomen and gluteal areas is not recommended for low molecular weight heparin (LMWH) injections. The abdomen is the preferred site for consistent absorption.

Choice C rationale

Massaging the injection site to increase absorption is not recommended for LMWH injections. Massaging can cause bruising and affect the absorption of the medication.

Choice D rationale

Expelling the air in the prefilled syringe prior to injection is not recommended for LMWH injections. The air bubble helps ensure the entire dose is administered and prevents medication from leaking out.

A. Report the client’s status to the healthcare provider. B. Ask the UAP to complete postmortem care. C. Begin cardiopulmonary resuscitation (CPR) and call a code. D. Notify the family of the client’s death. E. Notify the family of the client’s death.

Correct Answer is A

Explanation

Choice A rationale

Reporting the client’s status to the healthcare provider is the appropriate action. The healthcare provider needs to be informed of the client’s death to provide further instructions and complete necessary documentation. This action ensures proper communication and adherence to protocols.

Choice B rationale

Asking the UAP to complete postmortem care is necessary, but it should be done after notifying the healthcare provider. The nurse must follow the proper sequence of actions to ensure all protocols are followed.

Choice C rationale

Beginning cardiopulmonary resuscitation (CPR) and calling a code is not appropriate because the client has a signed do not resuscitate (DNR) form. Performing CPR would go against the client’s wishes and legal documentation.

Choice D rationale
Notifying the family of the client’s death is important, but it should be done after reporting the client’s status to the healthcare provider. The healthcare provider may have specific instructions for communicating with the family and completing necessary documentation.

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A nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a violation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching the client to self-administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?

Correct Answer is A

Explanation

An older adult client with heart failure has a signed do not resuscitate (DNR) form in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP’s findings. Which action should the nurse take next?

Correct Answer is A

Explanation

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

A nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a violation?

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